EMCrit Podcast 17 – Reversal of Anti-coagulant and Anti-platelet Drugs in Head Bleeds

So you have a patient with intracranial bleeding or you have a high pre-ct suspicion of intracranial bleeding and they are taking coumadin, aspirin, or clopidogrel. Should you reverse them? If so, how?

What if the CT is negative? Can you just discharge these patients as soon as they have a negative CT?

In this episode of the EMCrit Podcast, I discuss reversal of anti-coagulant drugs & anti-platelet medications, with particular emphasis on the prothrombin complex concentrates (PCC). I also touch on how to disposition these patients if their initial CT scan is negative.

CT Negative after Head Trauma while on Anti-coagulants or Anti-plt Meds

One man's jury-rigged approach:

Minor head trauma (the definition of this in the anticoagulant literature seems to be different than most other head trauma lit, they actually define minor as NO LOC and NO AMNESIA, just a bop to the head)

Most folks would still say scan these patients once and then observe for 6 hours. A few would say just observe, a very few would say admit for 24 hours. I watch them for 6 hours and then get the CT scan.

Head trauma with LOC, but GCS 15

definitely scan, definitely observe at least 6 hours, most would say either rescan or admit for 24 hours

Low Dose ASA led to secondary bleeding not seen on initial CT in patients with normal neuro exams (J Trauma 2009 67(3):521)

Update:

From EM:RAP Aug 2013

Nishijima DK et al. Immediate and delayed traumatic intracranial hemorrhage in patients with head trauma and preinjury
warfarin or clopidogrel use. Ann Emerg Med. 2012 Jun;59(6):460-8.
o A prospective, observational study at 2 trauma centers and 4 community hospitals. Most of these patients were community
hospital patients. They included patients with blunt head trauma who were using warfarin or Plavix. The patients were
followed for two weeks. They looked at what percentage of the patients had head bleeds and delayed head bleeds.
o 1,064 patients were enrolled (72% were on warfarin and 28% on Plavix). The prevalence of immediate traumatic intracranial
hemorrhage was higher in patients on Plavix than warfarin (12% versus 5%). This is high enough to recommend the use of
CT head in patients on these medications with trauma. A significant number of these patients had minor trauma, normal neuro
exam, no loss of consciousness and no evidence of trauma (11% with warfarin

Cite this post as:

Scott Weingart. EMCrit Podcast 17 – Reversal of Anti-coagulant and Anti-platelet Drugs in Head Bleeds. EMCrit Blog. Published on January 12, 2010. Accessed on January 21st 2019. Available at [http://emcrit.org/emcrit/reversal-head-bleeds/ ].

Financial Disclosures

Unless otherwise noted at the top of the post, the speaker(s) and related parties have no relevant financial disclosures.

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Nick Childs

Hi Scott, With regards antiplatelets and platelet infusions. Article from Medscape Reversal of Antiplatelet Therapy May Not Benefit TBI Laird Harrison October 29, 2013 SAN FRANCISCO — Patients with traumatic brain injury may not benefit from transfusions of platelets to reverse their antiplatelet therapy, a new study shows. “Reversal of antiplatelet therapy was not associated with decreased progression of intracranial injury,” said Joshua Bauer, MS, a researcher at the University of Pittsburgh in Pennsylvania. Bauer presented the finding here at the Congress of Neurological Surgeons (CNS) 2013 Annual Meeting. Patients with hemorrhage who are receiving antiplatelet or anticoagulant medication for conditions such as atrial fibrillation pose a dilemma for physicians. The antiplatelet treatment protects them from ischemic stroke, but may — theoretically at least — worsen their hemorrhage. Many neurologic surgeons administer platelet transfusion in hope of slowing or stopping the hemorrhage, the authors note, but few studies have examined the effectiveness of this therapy. To fill that gap, Bauer and his colleagues carried out a retrospective comparative cohort study, looking at 797 patients older than age 65 years receiving antiplatelet therapy who were treated for traumatic brain injury at the University of Pittsburgh from 2006 to 2010. Of these,… Read more »

This is a great talk. It’s funny because I’ve mentioned delayed bleeding in the past to admitting teams and they are usually unaware of this possibility. It definitely makes me think twice about sending these patients home at least without delayed observation in the ED.

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9 years ago

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emcrit

Faheem, thanks for commenting. It’s funny that the literature emerges from Neurosurgery and Trauma, and yet they are the services often most reluctant to admit.

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9 years ago

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Jeremy

We use Factor 7 for head bleeds in patients on warfarin. Should we be using the three-factor PCC along with this? (We have Beriplex (four-factor PCC) at our institution as a study drug, so I’ve seen it in action. I’m looking forward to using it when it’s approved in this country).

Not a huge fan of factor VIIa for head bleeds as it wears off quickly so the patient is back to anti-coag state and it makes the INR a lie, so you don’t know how effective your reversal. We use 3-factor exclusively and have gotten most of our patient’s reversed. The beriplex would be the ideal, so if you can get access that is what I would use.

Great talk.
We increasingly use PCC for anticoagulant associated head bleeds with good results. Factor VII would be a good option for patients needing emergent neurosurgical procedures such as an EVD placement. The combination of PCC and Factor VII would amplify the risk of thrombosis in a trauma patient with questionable benefit.
For Anti-platelet bleeds, we rarely transfuse platelets, since the benefit data is still lacking.

Abraham, The problem with factor VIIa for rapid neurosurg procedures is that while the coag tests will normalize; the patient may still be at increased bleeding risk. I think there is no advantage of VIIa over 4-factor PCCs for this use. Do you have evidence for the statement regarding the combination of PCC and VIIa. This combination is only for 3-factor PCCs and the VIIa you should add is to attempt to create something identical to 4-factor PCCs. The benefits are indisputable: 4-factor PCCs are more effective than 3 in the literature. The risks are tough to figure. The 4-factor you are creating is closer to FEIBA than beriplex or similar.

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6 years ago

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Sean Riley

Thank you for all of your work

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6 years ago

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Chris Johnson

Scott – I love the PCC’s.

But what are the downsides? Are there big clotting complications? Is it expensive? In other words, should this completely replace FFP for anything – the hemodynamically stable GI Bleed that needs reversal, etc? Why would I use FFP at all anymore?

Hi Scott, With regards antiplatelets and platelet infusions. Article from Medscape Reversal of Antiplatelet Therapy May Not Benefit TBI Laird Harrison October 29, 2013 SAN FRANCISCO — Patients with traumatic brain injury may not benefit from transfusions of platelets to reverse their antiplatelet therapy, a new study shows. “Reversal of antiplatelet therapy was not associated with decreased progression of intracranial injury,” said Joshua Bauer, MS, a researcher at the University of Pittsburgh in Pennsylvania. Bauer presented the finding here at the Congress of Neurological Surgeons (CNS) 2013 Annual Meeting. Patients with hemorrhage who are receiving antiplatelet or anticoagulant medication for conditions such as atrial fibrillation pose a dilemma for physicians. The antiplatelet treatment protects them from ischemic stroke, but may — theoretically at least — worsen their hemorrhage. Many neurologic surgeons administer platelet transfusion in hope of slowing or stopping the hemorrhage, the authors note, but few studies have examined the effectiveness of this therapy. To fill that gap, Bauer and his colleagues carried out a retrospective comparative cohort study, looking at 797 patients older than age 65 years receiving antiplatelet therapy who were treated for traumatic brain injury at the University of Pittsburgh from 2006 to 2010. Of these,… Read more »

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5 years ago

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SamG

Hey Scott,
Interesting emrap session this month discusses chronic liver disease patients and that they may truly actually be hypercoaguable (due to concomitant loss of proclotting factors, etc), and that INR doesn’t necessarily correlate with bleeding/clotting risk. Curious to know your take on the topic..

there is a post coming on the topic, but the answer is we don’t know. When they are bleeding, they have coagulopathy–there is no doubt. The question is do we need to reverse a non-bleeding patient for procedures, etc. I would like to see TEGs on these pts.

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4 years ago

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Dean Burns

Hey Scott

Given the recent publication of the PATCH trial, have you changed your recommendation from the point of view of advocating platelet transfusions for ICH patients taking anti-platelet medications?